CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

In Lieu of Services for chronic pain (non-pharmacologic therapies)

Defines Neighborhood Health Plan of RI coverage and limits for select non-pharmacologic 'in lieu of' services (chiropractic, acupuncture, massage) for members in Medicaid and INTEGRITY lines of business. Applies to providers requesting these services as substitutes for state plan services.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyIn Lieu of Services for chronic pain (non-pharmacologic therapies)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization using the Neighborhood In Lieu Of Prior Authorization Request Form with provider attestation that the service substitutes for a State Plan Service and meets medical necessity.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3types of covered in-lieu services

12chiropractic annual limit

12acupuncture annual limit

6massage therapy annual limit

90claim submission timeframe (days)

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Coverage criteria for In Lieu of Services

Covered when ALL of the following are met:

General eligibility: Member is in Medicaid or INTEGRITY line of business and service is requested as an 'in lieu of' substitution for a described State Plan Service (provider must attest on Neighborhood In Lieu Of Prior Authorization Request Form).

See scope and prerequisites

Medical necessity: All services must be medically necessary and determined effective for the member's pain and improvement in quality of health per Neighborhood review using NCD, LCD, InterQual, EOHHS recommendations, and Clinical Medical Policies.

Provider must supply supporting documentation

Service type: Requested service is one of the approved in‑lieu therapies: chiropractic, acupuncture, or massage therapy for chronic pain.

Only services listed in this policy are approved as In Lieu of Services

Services not listed in this policy are NOT approved as In Lieu of Services. This document specifically identifies only chiropractic, acupuncture, and massage therapy as approved in‑lieu services for chronic pain and does not authorize other modalities as substitutions for State Plan Services. (EOHHS approval applies to the services listed.)

This policy applies when a provider requests one of the identified services as a substitute for a described State Plan Service; the requesting provider must attest on the Neighborhood In Lieu Of Prior Authorization Request Form that the service is being used as an in‑lieu substitution and the member is eligible under the plan.

Services will only be covered when they are medically necessary and demonstrated to be effective for treatment of the member's pain and to improve the member's quality of health. Neighborhood determines medical necessity by referencing applicable standards including NCDs, LCDs, InterQual, EOHHS recommendations, and Clinical Medical Policies, and requires supporting documentation on the prior authorization form.

If a requested service does not meet these effectiveness or medical necessity requirements, or does not improve the member's health status as assessed under the referenced standards, the service will not qualify for reimbursement. Additionally, claim payment remains subject to member eligibility, benefit coverage, coding, documentation, and contractual rules and edits.

Attestation & conservative treatment requirements

Attestation via prior authorization form that service is an 'in lieu of' substitution and medically necessary

Provider attestation: Requesting provider has completed the Neighborhood In Lieu Of Prior Authorization Request Form attesting that the requested service is being used 'in lieu of' the described State Plan Service and is medically necessary.

Form and supporting documentation must be submitted as part of prior authorization

Prior authorization, documentation, and provider responsibilities

Prior Authorization

Prior authorization required

Prior authorization is required. Providers must submit the Neighborhood In Lieu Of Prior Authorization Request Form and include a provider attestation that the requested service is being used "in lieu of" the described State Plan Service. The requesting provider must attest that the service meets medical necessity and is appropriate for the member.

Use the Neighborhood In Lieu Of Prior Authorization Request Form for all in-lieu requests.
Attestation must state the service is being used "in lieu of" the specified State Plan Service.
Verify member eligibility, coverage, and authorization criteria prior to rendering services.

Documentation Required

Provider attestation and supporting documentation

Providers should complete the attestation on the Neighborhood In Lieu Of Prior Authorization Request Form and supply all required supporting documentation to substantiate the request.

Covered procedure codes

Covered procedure codes (by service type)CPTCovered

97110	Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility.
97112	Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities.
97124	Therapeutic procedure, 1 or more areas, each 15 minutes; massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion).
97140	Manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes.
97810	Acupuncture, 1 or more needles; without electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient.
97811	Acupuncture, 1 or more needles; without electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s) (List separately in addition to code for primary procedure).
97813	Acupuncture, 1 or more needles; with electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient.
97814	Acupuncture, 1 or more needles; with electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s) (List separately in addition to code for primary procedure).
98940	Chiropractic manipulative treatment (CMT); spinal, 1-2 regions.
98941	CMT; spinal, 3-4 regions.

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Service frequency limits (rolling year)

Chiropractic services — frequency limit

Limit12 visits per rolling year

Applies toChiropractic services used as an in‑lieu substitution for State Plan Services

Period typeRolling year

ScopeMembers covered when service is medically appropriate and approved by EOHHS

Acupuncture services — frequency limit

Limit12 visits per rolling year

Applies toAcupuncture services used as an in‑lieu substitution for State Plan Services

Imaging requirements

Billing Rule

Document imaging or diagnostic support when used to justify medical necessity

Document clinical rationale that the requested non-pharmacologic therapy is an appropriate substitute for the State Plan Service; include any relevant prior imaging or diagnostic findings relied upon to justify medical necessity.

Use the Neighborhood In Lieu Of Prior Authorization Request Form to record the in‑lieu substitution and clinical justification.
Include supporting diagnostic/imaging reports if they are part of the clinical rationale for the requested service.

Services not identified as covered In Lieu of Services

Any procedures or modalities other than chiropractic, acupuncture, or massage therapy are not identified in this policy as approved In Lieu of Services and therefore are not authorized as substitutions for State Plan Services under this policy.

Background and policy scope

Neighborhood may cover selected non‑pharmacologic therapies when it is determined the service is effective for treatment of a member's chronic pain and improves the member's quality of health. The services approved in this policy — chiropractic, acupuncture, and massage therapy — are intended to be used as alternatives to medications or invasive procedures when appropriate and when approved by EOHHS.

Coverage decisions will be made based on medical necessity review using recognized standards (for example, NCD, LCD, InterQual), EOHHS recommendations, and Neighborhood Clinical Medical Policies. Providers must attest via the Neighborhood In Lieu Of Prior Authorization Request Form that the requested service is being used 'in lieu of' the described State Plan Service and must verify member eligibility and coverage prior to providing services.

Key definitions

Definition — In Lieu of Services

TermIn Lieu of Services

DefinitionAlternative services used as substitutes for state plan services when medically appropriate and approved by EOHHS

Approval authorityRhode Island Executive Office of Health and Human Services (EOHHS)

Use caseProvided as medically appropriate therapy in place of other State Plan Services